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The Illusions of Psychiatry | by Marcia Angell | The New York Review of Books

Of the 170 contributors to the current version of the DSM (the DSM-IV-TR), almost all of whom would be described as KOLs, ninety-five had financial ties to drug companies, including all of the contributors to the sections on mood disorders and schizophrenia.5

Patients react better when doctors imply uncertainty, rather than state it directly -- ScienceDaily

Diagnostic uncertainty is widespread in clinical practice and physician guidelines generally recommend that doctors explain the degree of uncertainty associated with their diagnosis. However, how exactly doctors should communicate uncertainty is a matter of debate. This communication can lower visit satisfaction, decrease adherence to doctor instructions, lessen trust, and decrease confidence in the doctor.
The researchers here surveyed parents of pediatric patients who hypothetically received a diagnosis with an element of uncertainty. The uncertainty in the diagnosis was communicated in one of three ways; either with an explicit expression of uncertainty (such as "I'm not sure which disease this is"), an implicit expression of uncertainty using broad differential diagnoses (such as "it could be this disease or this other disease"), or another implicit expression of uncertainty (such as "it is most likely this disease"). Researchers found that explicit expressions of uncertainty were associated with lower perceived technical competence of the doctor, less trust and confidence, and a less willingness to adhere to doctors' advice.
"Misdiagnosis is common in medical practice and to enable improvements, uncertainty of diagnosis is something both doctors and patients will need to embrace" said Hardeep Singh, MD, MPH, senior author and researcher at the Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety and Baylor College of Medicine. "Our study provides a foundation for future development of evidence-based guidance on how doctors can best communicate diagnostic uncertainty to patients to improve diagnosis and care outcomes."

>50% medical journal editors get money from drug companies

The authors investigated 52 influential U.S.-based journals in 26 physician specialties. In 2014, approximately half the editors of these journals received payments from pharmaceutical or medical device companies. These payments were disclosed by the applicable companies in the U.S.-based Open Payments database a federally run program that requires industry to report information about financial relationships to physicians. These payments were made to the editors personally, rather than for research funding, and were characterized in various ways, including honorariums, patent royalties, food and beverage, travel expenses, and consulting fees. The highest payments went to editors from endocrinology journals, followed by cardiology, gastroenterology, rheumatology and urology.
The authors found that, on the whole, journal editors who are also physicians received higher payments from the pharmaceutical and medical device industries than physicians in their same specialty who are not journal editors.

Drug Abuse Among Doctors: Easy, Tempting, and Not Uncommon

Access rapidly becomes an addict's top priority, he notes, and self-medicating physicians will do everything in their power to ensure it continues.
"They're often described as the best workers in the hospital," he says. "They'll overwork to compensate for other ways in which they may be falling short, and to protect their supply. They'll sign up for extra call and show up for rounds they don't have to do." Physicians are intelligent and skilled at hiding their addictions, he says. Few, no matter how desperate, seek help of their own accord.

Stimulant Use Exceptionally High Among Medical Students

Of 148 medical students, 145 (98%) responded to the survey. The results revealed that 20% of students reported lifetime use of stimulants, with 15% reporting stimulant use during medical school.
Compared with Asian students, white students had a 9-fold increase in odds for stimulant use (P = .001). The investigators note that the sample size was not large enough to reliably compare prevalence of stimulant use in black and Hispanic medical students.
The researchers report that 13 students (9%) reported a diagnosis of ADHD and had an odds ratio of 37 for stimulant use in medical school compared with those without an ADHD diagnosis (P < .001).
The study also revealed that, of those who had taken stimulants, 83% used them specifically to boost cognitive performance, including improving focus while studying and staying awake longer while on clinical duty.
There were no differences in stimulant use by age, marital status, or academic achievement.
"Indeed, those with high standardized test scores had an almost identical use prevalence compared with those with lower test scores," the investigators report.
The majority (83%) of students who reported using stimulants used them specifically to improve cognitive performance.

My Stimulant Use in Med School: The Good, The Bad, The Victory » in-Training, the online magazine for medical students

ADD medications are generally marketed to “unleash the potential of the student,” which is accurate. In my case, I could finally barrel through those lecture notes without stopping five times to look at some shiny thing in order to earn a slightly below average grade on an exam (I’d stop only 2 times, instead).
Indeed, there is evidence to suggest that high-functioning students do not benefit from stimulant use the way lower-functioning students do. Of course, “high” and “low” functioning takes on a whole new meaning when we’re now splicing up classes of some of the highest achieving students from their colleges, but this is part of the issue in saying “ADD versus ‘normal.’” It’s really “ADD versus your potential.” The ability to synthesize complex ideas in my head had never been the issue, even through college (i.e. my intellect on its own was plenty strong). My ability to utilize this abstract synthetic ability was the issue, thus the obvious utility of Focalin.

The Heroism of Incremental Care - The New Yorker

Rose told me, “I think the hardest transition from residency, where we are essentially trained in inpatient medicine, to my practice as a primary-care physician was feeling comfortable with waiting. As an outpatient doctor, you don’t have constant data or the security of in-house surveillance. But most of the time people will get better on their own, without intervention or extensive workup. And, if they don’t get better, then usually more clues to the diagnosis will emerge, and the steps will be clearer. For me, as a relatively new primary-care physician, the biggest struggle is trusting that patients will call if they are getting worse.” And they do, she said, because they know her and they know the clinic. “Being able to tolerate the anxiety that accompanies taking care of people who are sick but not dangerously ill is not a skill I was expecting to need when I decided to become a doctor, but it is one of the ones I have worked hardest to develop.”

FDA Review ADHD Drugs Induce-Psychosis, Mania, Homicide, Suicide
http://www.fda.gov/ohrms/dockets/ac/06/briefing/2006-4210B-Index.htm
DATE: March 3, 2006
TO: Thomas Laughren, M.D., Director
Division of Psychiatric Products (DPP),
FDAOffice of Counter-Terrorism and Pediatric Drug Development (OCTAP) Memorandum.
FROM: Kate Gelperin, M.D., M.P.H., Medical Epidemiologist
Kate Phelan, R.Ph., Safety Evaluator
The DDRE ADHD Psychiatric Review Team
Office of Drug Safety (ODS)
1 EXECUTIVE SUMMARY / INTRODUCTION
A BPCA (Best Pharmaceuticals for Children Act) review of methylphenidate products, prompted by Concerta pediatric exclusivity requirements, identified psychiatric adverse events as a possible concern. The review found some psychiatric adverse events mentioned in labeling, but a need for improved clarity was identified. The Pediatric Advisory Committee1 agreed at the June 2005 meeting at which the methylphenidate reviews were discussed, that the issue of psychiatric adverse events with all drugs indicated to treat ADHD should be examined with the goal of better characterizing these events so that drug labeling could be updated and made consistent between products. Thus, DDRE embarked on reviews of postmarketing and clinical trial reports of psychiatric adverse events associated with drugs used to treat ADHD. This document presents the results of the review of postmarketing reports. A companion document2, from Dr. Andrew Mosholder, presents the results of the review of clinical trial reports.
Information pertaining to selected psychiatric adverse event reports received since January 1, 2000 was requested from the manufacturers of products approved or with pending applications for the treatment of ADHD. Sponsors were asked to provide information regarding four broad categories of psychiatric adverse events: 1) signs and/or symptoms of psychosis or mania; 2) suicidal ideation and behavior; 3) aggression and violent behavior; and, 4) miscellaneous serious adverse psychiatric events. In addition, searches of the FDA AERS safety database were conducted covering the same time period, and the identified cases were assessed by a DDRE Review Team. Duplicates, and reports which were considered to be of poor quality or highly unlikely to be related to the drug of interest were excluded from this analysis.
Cases received from Sponsors, as well as those identified from the FDA AERS safety database, were systematically reviewed and analyzed to assess the probability of adverse drug reactions and to describe characteristics or risk factors observed in these reports. This review focuses on postmarketing safety data from the first three search categories. The miscellaneous category was considered to be beyond the scope of this current analysis due to the large volume of data for review.
The most important finding of this review is that signs and symptoms of psychosis or mania, particularly hallucinations, can occur in some patients with no identifiable risk factors, at usual doses of any of the drugs currently used to treat ADHD. Current approved labeling for drug treatments of ADHD does not clearly address the risk of drug induced signs or symptoms of psychosis or mania (such as hallucinations) in patients without identifiable risk factors, and occurring at usual dosages. In addition, current labeling does not clearly state the importance of stopping drug therapy in any patient who develops hallucinations, or other signs or symptoms of psychosis or mania, during drug treatment of ADHD. We recommend that these issues be addressed.
A substantial proportion of psychosis-related cases were reported to occur in children age ten years or less, a population in which hallucinations are not common. The occurrence of such symptoms in young children may be particularly traumatic and undesirable, both to the child and the parents. The predominance in young children of hallucinations, both visual and tactile, involving insects, snakes and worms is striking, and deserves further evaluation. Positive rechallenge (i.e., recurrence of symptoms when drug is re-introduced) is considered a hallmark for causality assessment of adverse events. Cases of psychosisrelated events which included a positive rechallenge were identified in this review for each of the drugs included in this analysis.
In many patients, the events resolved after stopping the drug. In the FDA AERS review, resolution of the events after stopping the drug was reported in 58% of amphetamine /dextroamphetamine cases, 60% of modafinil cases, 33% of atomoxetine cases, and 48% of methylphenidate cases. (Note: Outcome of the psychiatric adverse events was not reported in 21% of amphetamine / dextroamphetamine cases, 9% of modafinil cases, 41% of atomoxetine cases, and 30% of methylphenidate cases.) For drugs currently approved for ADHD treatment, no risk factors were identified which could account for the majority of reports of psychosis-related events. For instance, drug abuse was reported in fewer than 3% of overall cases from the FDA AERS analysis of psychosis-related events. Also of note, in the overwhelming majority of cases (roughly 90% overall), the patient had no prior history of a similar condition.
Numerous postmarketing reports of aggression or violent behavior during drug therapy of ADHD have been received, most of which were classified as non-serious, although approximately 20% of cases overall were considered life-threatening or required hospital admission.

What patients say and what doctors document: Comparison of medical record to self-report of eye symptoms shows wide variation -- ScienceDaily

Symptom reporting drove the inconsistencies between surveys and medical records, the study found.
The top discordant issue: glare. Of patients reporting concern about glare on their surveys, 91 percent didn't have it on their medical record.
Eye redness was second-most common (80 percent had no medical record mention), followed by eye pain (74.4 percent). Blurry vision was only the symptom to tilt the scales -- with more instances of inclusion in medical records than in questionnaires.